Correspondence to Nigusie Selomon Tibebu; [email protected]
STRENGTHS AND LIMITATIONS OF THIS STUDY
This study strives for local policymakers and responsible bodies.
Because it was community-based, the study might have experienced fewer instances of bias.
It may not be a sweeping statement for other age groups of children.
It was focused on children’s characteristics rather than environmental factors.
The study is cross-sectional; it does not show a cause-and-effect relationship between wasting and associated factors, and it uses a single outcome measurement technique.
Introduction
In low-income and middle-income nations, undernutrition is the most prevalent type of malnutrition. It shows up as stunting, underweight, wasting and a lack of vitamins and minerals. Consequently, it is one of the main causes of morbidity and mortality in children.1
The Ethiopian government is dedicated to enhancing the nutritional condition of its people. By way of the creation of a National Nutrition Strategy in 2008 and a National Nutrition Program that followed, the government has likewise shown a significant governmental commitment to nutrition (2008–2015). The Seqota Declaration, a high-level commitment to eradicating child undernourishment by 2030, is a part of the follow-up National Nutrition Program II, which was introduced in December 2016.2
Wasting is acute malnutrition that has harmful short-term consequences for children and is determined by an inadequate diet. Furthermore, it is a direct cause of mortality among children 6–59 months of age.3 Wasting is a state of nutritional deficiency that brings severe health consequences, the most immediate being a pointed risk of mortality.4
Globally, wasting accounts for more than 51 million children.5 Each year, more than 800 000 deaths are attributed to wasting. Moreover, approximately 13% of worldwide deaths among children under 5 years of age were attributed to wasting in 2015, representing 875 000 preventable child deaths.4 There has been less progress in reducing the number of wasted children worldwide.6 Africa and Asia stand the greatest point of wasting.6 In Ghana 9.9%,7 East Africa 6%,8 Uganda 12%,9 the study done in Ethiopia 17%,10 in Somalia regional state of Ethiopia 20%,11 in South Ethiopia 14.6%,12 East Bedawacho district, South Ethiopia 7.6%,12 in Sodo Zuria, South Ethiopia 11.1%,8 Damot Gale, South Ethiopia 9%,13 in Afar regional state of Northeast Ethiopia 16.2%,14 in Northern Ethiopia 24.6%,15 in Lalibela Amhara region 8.9%,16 in Gondar city, Northwest Ethiopia 7.3%,17 in Western Amhara 11.6%18 and in East Belesa district, Northwest Ethiopia 16%.19
According to the Ethiopia Demographic and Health Survey (EDHS) of 2019, the prevalence of wasting was 7%.20 The prevalence of wasting has decreased considerably from 12% in 2005 to 7% in 2019 but in Ethiopia, the burden of child wasting has continued as a severe public health problem for decades.20
About one-third of deaths among children below 5 years of age were attributed to undernutrition, which can lead children to be at greater risk of death and severe illness due to common childhood infections and consequently lead to low school performance and physical and mental impairment.15 21
According to the revision of the literature, the following contributing factors to wasting in children were: intrauterine growth retardation, low birth weight, inadequate exclusive breast feeding, inappropriate complementary feeding, low maternal education, low nutritional knowledge, insufficient energy and less micronutrient intake; birth spacing; socioeconomic background; less food availability; poor sanitation; poor health services; low vaccination coverage; and infectious diseases.5 22–25
Even though studies have mentioned different factors affecting the existence of waste in children, no studies have been done in this area. The other reasons for conducting this study included the need to contribute data encoding on the nutritional health of under-5 children and the growing interest of governments and development organisations in the relationship between nutritional health and the requirement for a national school health policy, particularly in the study area of Ethiopia. Therefore, this study aimed to assess the burden and associated factors of wasting among children aged 6–59 months in Debre Tabor town, Northwest Ethiopia.
Methods and materials
Study design
A cross-sectional study was conducted in Debre Tabor town, Northwest Ethiopia, from 1 to 30 March 2019. The source population was all children aged 6–59 months in Debre Tabor town during the specified study period. The study population consisted of all selected children aged 6–59 months in Debre Tabor town during the specified study period. All children aged 6–59 months and their mothers with complete information. Verbal consent was taken from mothers or guardians. Socio-demographic, maternal and child characteristics were used as independent variables.
Patient and public involvement
None.
Sample size determination and sampling procedure
The sample size for the study was determined using the assumptions of the single population proportion formula assuming the prevalence of wasting of 16%,19 5% margin of error, 95% confidence level, added 10% for possible non-response rate and design effect of two, the calculated sample size was 454.
Out of six kebeles (the smallest administrative unit in Ethiopia), four kebeles were selected randomly. The total sample size was allocated to each kebele proportionally. Households were selected systematically (even if proportional allocation was done for each cluster, for further issues of representativeness, the data collectors were started randomly from one household, and the first non-registered question was, ‘Have 6–59 month-old children in this household?’ If not, the assigned data collectors on each cluster were moved to the next household, and when there is more than one child 6–59 months of age in the selected household, a lottery method is used to randomly select the child.
Data collection tools and data quality control
A structured questionnaire was created using information from other studies on related subjects and WHO STEPS for child malnutrition surveillance. However, a wealth status-related questionnaire from the 2016 EDHS was adopted and mothers and guardians were interviewed face-to-face. Four bachelor’s degree graduates with prior experience in data collection and fluent speakers of the local language were recruited.
The training was given to data collectors and supervisors about the questionnaire, selecting study participants, anthropometric measurements and ethics. They were also standardised for taking anthropometric measurements. The questionnaire was pretested on 5% of the actual sample size other than the study area. The length of a child (aged 6–23 months) was measured with a horizontal wooden length board in a recumbent position. The height of a child (aged 24–59 months) was measured with a vertical wooden height board while the child was standing upright on the board. The length and height measurements were read to the nearest 0.1 cm. The weight was measured using a Seca digital weight scale and read to the nearest 0.1 kg. All measurements were taken twice and the mean was used for analysis. Supervisors checked the completeness and consistency of the questionnaire.
Dependent variable
Wasting (below −2 SD WHO z-score) children aged 6–59 months.
Independent variables
Socioeconomic and demographic variables (age, educational level, marital status, family wealth and family size).
Maternal characteristics (antenatal care start month, family planning use, age at first birth).
Childs’s characteristics (age, sex of the child).
Operational definitions
Wasting is the weight-for-height z-score is below –2 SD of the WHO median standard curve.6
Data analysis
The data was checked, sorted, categorised and coded. After coding the data, it was fed to the computer to make it ready for processing and analysis. Data was entered into the Epi Info (V.7.2.0.1) and analysed using the SPSS V.20.0 statistical programme. Anthro software was used to convert nutritional data into z-scores of the indices; weight-for-height took age, sex, weight and height into consideration using WHO standards; and principal component analysis was used to compute family wealth status. Tables and charts were used to present the results. Binary logistic regression was used to identify variables associated with wasting and variables significant at p<0.25 were entered into the final multivariable logistic regression model to identify significant factors at p≤0.05.
Result
Socio-demographic factors of the study participants
From a total of 454 proposed study participants, 436 with a 96% response rate were included in the analysis. Among the total participants, 388 (89%) were married in their marital status, and the majority (297, or 68.1%) were fathers who have a secondary or above education level. The majority of the 176 (40.4%) were rich in family wealth status (table 1).
Table 1Characteristics of participants for wasting among children age from 6 to 59 months in Debre Tabor town, Amhara Region of Ethiopia, 2019 (N=436)
| Characteristics | Categories | Total | Status of a child | |
| Wasted | Not wasted | |||
| Mothers’ age group Mean=31±5.41 SD | 20–24 | 31 (7.1%) | 6 (1.4%) | 25 (5.7%) |
| 25–29 | 181 (41.5%) | 11 (2.5%) | 170 (39.0%) | |
| ≥30 | 224 (51.4%) | 10 (2.3%) | 214 (49.1%) | |
| Mother age group at first birth | 20–25 | 97 (22.2%) | 12 (2.8%) | 85 (19.4%) |
| 26–29 | 238 (54.6%) | 8 (1.8%) | 230 (52.8%) | |
| ≥30 | 101 (23.2%) | 7 (1.6%) | 94 (21.6%) | |
| Mothers’ educational level | No formal education | 99 (22.7%) | 8 (1.8%) | 91 (20.9%) |
| Primary education | 105 (24.1%) | 7 (1.6%) | 98 (22.5%) | |
| Secondary education and above | 232 (53.2%) | 12 (2.8%) | 220 (50.4%) | |
| Fathers’ educational level | No formal education | 56 (12.8%) | 5 (1.1%) | 51 (11.7%) |
| Primary education | 83 (19%) | 9 (2.0%) | 74 (19.0%) | |
| Secondary education and above | 297 (68.1%) | 13 (3.0%) | 284 (65.1%) | |
| Mothers’ occupational status | Housewife | 215 (49.3%) | 17 (3.9%) | 198 (45.4%) |
| Merchant | 62 (14.2%) | 2 (0.5%) | 60 (13.7%) | |
| Government employ | 108 (24.8%) | 3 (0.7%) | 105 (24.1%) | |
| Others* | 51 (11.7%) | 5 (1.1%) | 46 (10.6%) | |
| Fathers’ occupational status | Merchant | 122 (27.9%) | 6 (1.4%) | 116 (26.5%) |
| Government employ | 201 (46.1%) | 7 (1.6%) | 194 (44.5%) | |
| Others* | 113 (25.9%) | 14 (3.2%) | 99 (22.7%) | |
| Marital status of a mother | Married | 388 (89%) | 20 (4.6%) | 368 (84.4%) |
| Single | 48 (11%) | 7 (1.6%) | 48 (9.4%) | |
| Family planning use | Yes | 323 (74.1%) | 19 (4.4%) | 304 (69.7%) |
| No | 113 (25.9) | 8 (1.8%) | 105 (24.5%) | |
| Antenatal care start month | ≤3 months | 291 (66.7%) | 18 (4.1%) | 273 (62.6%) |
| >3 months | 145 (33.3%) | 9 (2.0%) | 136 (31.3%) | |
| Family size | <5 | 350 (80.3%) | 20 (4.6%) | 330 (75.7%) |
| ≥5 | 86 (19.7%) | 7 (1.6%) | 79 (18.1%) | |
| Sex of child | Male | 233 (53.4%) | 11 (2.5%) | 222 (50.9%) |
| Female | 203 (46.6%) | 16 (3.7%) | 187 (42.9%) | |
| Child age | 6–11 months | 131 (30%) | 13 (3.0%) | 118 (27.0%) |
| 12–23 months | 105 (24.1%) | 8 (1.8%) | 97 (22.3%) | |
| 24–59 months | 200 (45.9%) | 6 (1.4%) | 194 (4.5%) | |
| Family wealth status | Poor | 142 (32.6%) | 14 (3.2%) | 128 (29.4%) |
| Medium | 118 (27.1%) | 8 (1.8%) | 110 (25.3%) | |
| Rich | 176 (40.4%) | 5 (1.1%) | 171 (39.3%) | |
*Daily labourer.
Wasting among children aged from 6 to 59 months in Debre Tabor town, Amhara region of Ethiopia
Of the total participants of the survey aged from 6 to 59 months of children, 6.2% (95% CI: 3.9% to 8.5%) were found wasted (figure 1).
Enlarge this image.Figure 1. Prevalence of wasting among children aged from 6 to 59 months in Debre Tabor town, Amhara region of Ethiopia, 2019.
Factors associated with wasting among children age from 6 to 59 months in Debre Tabor town, Amhara region of Ethiopia
Bivariable and multivariable logistic regression analyses were used to determine factors affecting the waste of children aged from 6 to 59 months. The bivariable analysis showed that the educational status of the father, educational status of the mother, age of the child, wealth status of the family, age of the mother and age of the mother at first birth were associated with wasting, considering a p value<0.2. For adjusting potential confounders, those variables that were significant at bivariable analysis were entered into multivariable logistic regression. The result revealed that the age of the child, wealth status of the family and age of the mother at first birth were significantly associated with wasting in children aged 6–59 months. However, the remaining listed variables were not significant at a p value<0.05
Children in the age group of 6–11 months were 4.3 times more likely to have wasted than those in the age group of 24–59 months (adjusted OR (AOR): 4.3; 95% CI: 1.5 to 12.5). Similarly, parents who have poor wealth status in their family are 3.1 times more likely to have wasted children than those who have rich wealth status in their family (AOR: 3.1 (1.01 to 9.35)). Children of mothers who gave birth at the age group of 20–25 years were 4.3 times more likely to have wasted their lives than those who gave birth at the age group of greater than 30 years (table 2).
Table 2Bivariate and multivariable logistic regression analyses for wasting among children age from 6 to 59 months in Debre Tabor town, Amhara region of Ethiopia, 2019 (N=436)
| Variables | Categories | COR/95% CI | AOR/95% CI |
| Mothers’ education | No formal education | 1.61 (0.63 to 4.07) | 2.11 (0.57 to 7.81) |
| Primary education | 1.31 (0.50 to 3.42) | 2.24 (0.78 to 6.44) | |
| Secondary education and above | 1 | 1 | |
| Fathers’ education | No formal education | 2.14 (0.73 to 6.27) | 1.01 (0.32 to 3.15) |
| Primary education | 1.31 (0.50 to 3.64) | 0.93 (0.33 to 2.63) | |
| Secondary education and above | 1 | 1 | |
| Mothers’ age group | 20–24 | 5.13 (1.72 to 15.33) | 3.09 (0.87 to 10.95) |
| 25–29 | 1.39 (0.57 to 3.33) | 1.63 (0.63 to 4.19) | |
| ≥30 | 1 | 1 | |
| Mothers’ age group at first birth | 20–25 | 4.06 (1.31 to 9.62) | 4.35 (1.56 to 12.5)* |
| 26–29 | 1.89 (0.71 to 5.03) | 0.67 (0.22 to 2.00) | |
| ≥30 | 1 | 1 | |
| Child age | 6–11 months | 2.56 (1.31 to 9.62) | 4.32 (1.49 to 12.55)* |
| 12–23 months | 2.67 (0.90 to 7.90) | 2.58 (0.82 to 8.1) | |
| 24–59 months | 1 | 1 | |
| Family wealth | Poor | 3.74 (1.31 to 10.65) | 3.07 (1.01 to 9.35)* |
| Medium | 2.49 (0.79 to 7.79) | 2.53 (0.76 to 8.38) | |
| Rich | 1 | 1 |
1=reference group.
*Significant p value<0.05.
AOR, adjusted OR; COR, crude OR.
Discussion
The assessment of wasting in this study is based on the reference population of referenced children, as advised by the WHO. SD units from the median for the reference groups are used to express the weight-for-height. Wasted children are those who are less than −2 SD from the median reference population.
Undernutrition among children aged 6–59 months is still a major public health problem in developing countries, including Ethiopia. The magnitude of wasting in this study was 6.2% (95% CI: 3.9% to 8.5%). The age of the child, the wealth status of the family and giving the first birth before 20 years of age were associated with higher odds of wasting in this age group. The magnitude of wasting has been found in different study settings, from local to global.
This study was in line with the study done at Gondar city, Northwest Ethiopia 7.3%,17 East Bedawacho district, South Ethiopia 7.6%,12 Wolayta Sodo Town, Southern Ethiopia 7.8%26 EDHS 2019 7%20 and in East Africa 6%.8
However, this study was lower as evaluated to the study done in East Belesa district, Northwest Ethiopia 16%,19 in Western Amhara region, Ethiopia 11.6%,18 Northern Ethiopia 24.6%,15 Afar regional state, Northeast Ethiopia 16.2%,14 Damot Gale, South Ethiopia 9%,13 Sodo Zuria, South Ethiopia 11.1%,8 in South Ethiopia 14.6%,12 Somalia regional state of Ethiopia 20%,11 a study done in Ethiopia 20%,10 Uganda 12%,9 in Ghana 9.9%.7 The possible reason might be due to different study periods and most studies were nationwide while this study was specific to Debre Tabor town, Ethiopia. The continuation magnitude of wasting in this study was determined by significantly associated factors.
In the present study, children’s age was one of the predictors of wasting among children aged 6–59 months. Children who had 6–11 months of age were more likely to have wasted than 24–59 months of age. The result is supported by the research done in North Shewa Oromia, Ethiopia,22 Lalibela, Northern Ethiopia,16 Uganda27 and Myanmar, South Asia.28 The possible justification might be, with an increase in the child’s age, the frequency of wasting decreases due to the increased susceptibility of younger children to infection/illness.24
Another predictor of wasting for children aged 6–59 months was family wealth status. In this study, families who have poor wealth status were more likely to have wasted children than those families who have rich wealth status. This study is supported by the study done in Uganda,9 Gondar town Northwest Ethiopia17 and Dabat, Northwest Ethiopia.10 The possible reason might be that children who have poor family wealth status lack adequate nutrition in their household which leads to a nutritional imbalance between demand and supply.
The last predictor of wasting for this study was maternal age at first birth. Children of mothers who gave birth at the age group of 20–24 years were more likely to have wasted children than those who gave birth at the age group of greater than 30 years. The possible reasons might be due to the high demand for nutrition at first conception which again leads to the child being wasted. Furthermore, the income of youngsters has a great impact on their family’s nutritional status since most of them within the age group of 20–24 are unemployed.
Overall, the implication of this study was the prevalence of wasting, along with any potential contributing factors in the area that had not previously been the subject of study. In the meantime, for policymakers to develop effective intervention measures, assessments of children’s nutritional status are crucial tools. Besides, childhood undernutrition exposures have an impact on an individual’s quality of life, employment capability, physical development and health throughout their entire lifetime. Furthermore, to save future generations, the under-5-year-old children’s nutritional needs should be at the centre of all nutrition programmes planned by the town health office. This demands special attention at every level, starting with kebeles. To address the issues of wasting and other health-related obstacles at the community level, a community-based nutrition programme targeting under-5 children should be implemented, and the presented (like the Seqota Declaration) programmes should also be strengthened and widened.
Conclusion
Undernutrition, especially wasting, is still an important public health problem in children in the age group of 6–59 months. The age of the child, the wealth status of the family and giving birth before 20 years of age were significantly associated with wasting. Therefore, the government of Ethiopia should pay further attention to the wealth status of the family; create awareness among the mothers regarding childhood undernutrition care, and design further nutritional intervention programmes. The researchers also suggested future research based on trend analysis which was required to determine the trend in under-5 wasting and key determinants to meet the targets of the Sustainable Development Goals.
The authors would like to thank Amhara Regional Health Bureau for its financial support. Besides, we want to acknowledge data collectors and supervisors for their commitment to collecting the data accurately. Finally, we thank English language experts for their professional input.
Data availability statement
Data are available upon reasonable request. Data will be available upon request from the corresponding author.
Ethics statements
Patient consent for publication
Consent obtained from parent(s)/guardian(s).
Ethics approval
Ethical clearance was obtained from the school of the nursing ethical review committee on behalf of the University of Gondar review board (Ref No, 1601/06/2011). The verbal informed consent was acceptable and approved by the ethical review board on behalf of the University of Gondar. A permission letter was obtained from the Debre Tabor town Department of Health. Participants were informed about voluntarism and that they can withdraw at any time during the study if they did want not to respond. For those who were a volunteer to participate, verbal informed consent was obtained from the parent/legal guardian/for the children involved in this study. At the end of the interview, participants were informed about wasting and its associated potential effects, and wasted children were linked to the nearest health institution.
Contributors Authors (BDG, KAAz, NST, LYZ and GMA) made substantial contributions to the conception, design, acquisition of data or analysis and interpretation of data, and (NST, BDG, TDE and KAAt) took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published, and agree to be accountable for all aspects of the work. All authors have read and approved the final manuscript. BDG is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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Details
; Emiru, Tigabu Desie 2
; Atalell, Kendalem Asmare 3
1 Department of Nursing, Debre Tabor Health Sciences College, Debre Tabor, Ethiopia
2 Department of Pediatrics and Child Health Nursing, Debre Tabor University, Debre Tabor, Ethiopia
3 Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia